Provider Demographics
NPI:1336251008
Name:GUSTAFSON, STEVEN D (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:D
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 E 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1968
Mailing Address - Country:US
Mailing Address - Phone:248-541-8770
Mailing Address - Fax:
Practice Address - Street 1:940 E 11 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1968
Practice Address - Country:US
Practice Address - Phone:248-541-8770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI13897122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist